Your Questions
Your Questions
Q: Dr. Eppley, I was reviewing your Patriotic Program for plastic surgery. Honestly, I never in my wildest dreams thought I could receive a military discount for cosmetic surgery. I’m interested in having a consultation for an Tummy Tuck and liposuction around my knees. I have been waiting for close to 10 years to do this surgery. I think now is the time. My husband of almost 20 years is now serving in Afghanistan.
He should be home in the next two months. That being mentioned, I would like to be healed buy the time he comes home and look fantastic or at least as good as it gets. My husband has been telling me to go ahead and do it but I never do. I always find other ways to spend the money. I know I will feel so much better when my clothes fit nice and I don’t have to wear spanks…especially in a formal gown. Yep, I know I have at least 4 more formals to attend before retirement because of my four children. Thank you so much for taking your professional time to support our troops and their families using your gift.
A: Tummy tuck surgery can make a dramatic difference in your body shape and how you fit in clothes. Since you are done having children the results of a tummy tuck can last a lifetime and is one investment that cap pay dividends for decades.
We have offered military discounts for years for a wide variety of cosmetic surgery procedures. We are happy to do so and try to make a small contribution to those that serve or have served to protect the freedoms for what we have the opportunity
to choose to do every day.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an otoplasty for protruding ears one year ago. From the beginning my left ear has not been symmetrical to my right ear. The top part sticks out a little bit more and it bothers me. I want to have revisional surgery for it. I am assuming that a revision otoplasty is simpler with less recovery than the first one? Also, how likely is it that the ears will end up the same? It would seem like it is easier now that only one is being changed as opposed to two ears. Lastly, since the left ear will have had two surgeries will it end up being weaker than the right? If it gets hit is it more likely to spring back out again if it is weaker?
A: You are correct in assuming that only one ear is less invasive and easier than operating on both ears. Also a revision of an otoplasty in any one ear is less invasive than the original since usually only an additional plication suture or two has to be placed. Given that yours is just the top part of the ear, only the upper half of the incision has to be re-opened for suture placement. This also means that such a revision can usually be done under local anesthesia. Certainly a revision is going to get your ears closer in symmetry but I would not expect perfection. It is unlikely that your ears were perfectly the same before surgery so you should not expect perfect ears after surgery either. The revised ear will not end up being weaker since no cartilage is removed, it is just folded back further.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My nose has a lot of things about that I don’t like and want to change. It has never been broken or anything so I think I was just born with this shape of a nose. What bothers me about it are several things. First, I don’t like the thick broad tip that I have. It needs to be thinned and made more narrow. I also think the tip is too long. Second, I don’t like the nasal bump that I have. My nose is not smooth from between the eyes down to the tip due to this bump. I also think that the bump makes the nose broader up top. I guess when you put these two things together, I pretty much want a whole new nose. I am wondering if a lot of these changes are possible.
A: Essentially your redo of your whole nose is known as a complete septorhinoplasty. Through an open approach all segments of the nose are addressed. The hump is taken down, the upper nasal bones are narrowed, the tip is reduced and narrowed and the dorsal line of the nose is made smooth. If needed the septum is also straightened, or at the least, used for cartilages grafts which are almost always needed. This is a complete overhaul of the nose and substantial changes can be obtained. All of what you are describing is both possible and also common im rhinoplasty surgery. Make sure you get some computer imaging done before surgery so you will be prepared for what these structural changes will potentially look like.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 34 year old woman who has had two children. I am done having children and now want to address the damage done to my breasts by pregnancy and breast feeding. I have lost all of my breast volume and they sag. I want breast implants but I don’t want a breast lift. I don’t want the scars from the lift. I would be ok with small hidden scars but nothing that goes beyond the border of the nipple and the skin. I have attached some pictures of my breasts. Can you tell me if what I am asking is reasonable?
A: Unfortunately, there is a significant difference between what you need for a good breast result and what you want. You are not alone in this position as many women need a breast lift but don’t want the scars. You have too much sagging to get a good result using breast implants alone. In fact, implants without a lift is going to make your breasts look worse not better. They will create a mound above the current level of your hanging breast tissue and will merely end up placing your nipple on the bottom half of the implants. This will create a breast appearance that you will likely not find better. It will just be trading into a different type of breast deformity.
If you are not ready to accept scars as of yet, you can always have breast implants first and let the result prove to you whether that look may be acceptable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am entertaining the thought of a breast lift only. So I am researching a little bit. I am 50 yrs old and have always had nice naturally large breasts but with age they are hanging low but not flat yet. I’m a Size D now. My question is with a lift only does the procedure reduce the size when they are lifted? I’m sure some liposuction etc is needed so that seems to me it would take them down at least one size naturally. Is that correct? I’m thinking it would not be so bad as with age our backs take a toll carrying them around our whole lives, so smaller could be a good thing. Thank you for your time.
A: A breast lift, in its purest form, does not reduce the size of the breast. It lifts it, tightens the skin envelope and moves the nipple position into a more central position on the breast mound, but it removes no breast tissue. This is what separates it from a breast reduction procedure which also removes a significant amount of breast tissue. But variations can be done to a breast lift procedure to provide both a lift and a small amount of breast reduction. It is this procedure that you appear to be seeking by description. This combination breast lift-reduction procedure involves the removal of between 100 to 200 grams of breast tissue which will reduce the size of the breast by a ½ cup or so. Liposuction can also be done on the side of the breast into the back, an area which is outside the direct effect of any breast reshaping procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have finally decided as an adult to have my cleft lip scar and nose asymmetry repaired. What I don’t like about my face is that I have a prominent lip scar, a downturned and twisted nose and an overall flatter face. I have attached some pictures so you can clearly see what I mean. What specific procedures do you think I will need and how are they done?
A: Thank you for sending your pictures. You have many of the very typical lip/nose/midface cleft-induced deformities that many so affected patients have. In analyzing how to make a significant improvement, I would recommend the following approach. A full septoprhinoplasty is needed to straighten out the whole nose and give the tip more projection and some narrowing. You would need a cartilage rib graft to build up the base of the nose (pyriform aperture/paranasal regions) by onlay grafting and as a columellar strut to improve tip projection and support. Your cleft lip repair is pretty good at the cupid’s bow area but I would excise the philtral scar and re-unite the underlying orbicularis muscle better.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have one calf that is extremely lager than the other, I always had nice legs and nice calves, I dont have bulging veins, but because I am very fair in complexion, my veins were very visible, so i had the vein injected by a podiatrist . ever since that my left calf has progressively gotten bigger. Please let me know if I can get plastic surgery to reduce this calf as to me it is unsightly, so much i dont want to wear a dress. Help!!!!
A: The first question is how long ago was the vein injected and why did it become bigger after. Calf enlargement is not an expected outcome from sclerotherapy, unless has developed a deep vein thrombosis. If the injection was done recently and you have pain in that calf, then I would recommend that you have it evaluated with an ultrasound to make sure you have not developed a DVT.
From a calf reduction standpoint, there are only two approaches. Either reduce the fat around the calf via small cannula liposuction or muscle reduction. Muscle reduction can be done by Botox injections or denervation but there are considerable costs and some surgical risks with either approach. Liposuction contouring is the simplest and whether that would be effective depends on how much subcutaneous fat exists around the calf area. At a minimum I at least need to see a picture of calfs to determine if that is possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I currently have mandibular angle implants but they are just slightly too large and I would like to get them shaved or switched for a slightly smaller pair. 1.) How difficult is the process of shaving them down? 2.) Is the recovery time just as bad as when they were first placed? 3.) Do you recommend shaving them down or switching them out for a smaller pair? Thank you in advance for your response.
A: Modification of jaw angle implant size is certainly easier than the first procedure. This is because the submuscular/subperiosteal pockets have already been made. This is what causes the real trauma and swelling from their original placement. While there will be some swelling the second time around, it will not be as bad as the first. Whether you modify in size or get new jaw angle implants depends on what type of implant was placed (silicone vs medpor) and what is the dimension that you want changed. If it is a silicone implant, I would just replace it with a smaller size as their cost is very low. If they are porous polyethylene (Medpor), I would shave down the existing implants because their cost replacement is substantially higher and they are easy to shave down after they have been implanted for awhile. (get softer with hydration)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I would like to know if I am a candidate for short scar upper arm lift. I had liposuction of the upper arms done 1 1/2 years ago. Since then, my upper arms sag moderately. Thank you
A: Without seeing pictures of your arms, I can only conjecture as to the utility of a short scar armlift in your case. But having had liposuction previously with ‘moderate’ sagging now present, you may well be a candiddate. It depends on exactly where the greatest amount of sagging skin is. The closer it is to your armpit or upper half of the arm, the more likely a limited armlift may be of benefit. It will result in no improvement near the elbow or lower half of the arm.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have what I would consider a significant amount of lipoatrophy in my face (and I’m HIV positive for almost 4 years). I also unfortunately had a small amount of buccal fat removed when I was younger. That, combined with the lipoatrophy, has left my cheeks, buccal, and temporal areas looking quite thin (and in my view, gaunt). What do you feel is the best way of treating this fat loss? I’m not really interested in an implant due to cost and I really am interested in restoring volume. I have had Sculptra treatments previously, but the results were not long lasting and did not restore an adequate amount of volume in my view. I have considered facial fat grafting, but am concerned about the reliability of whether that fat would survive (especially in someone with HIV). I am interested in your thoughts as to what the best course of treatment may be for something that is not short lasting and not outrageously expensive.
A: The only reliable permanent method of restoring volume in the malar, submalar and temporal regions are with implants. Malr shell and temporal implants will do well in those areas. Injectable fat grafting is another alternative, and the least costly one, but its reliability on someone on antiviral medication is very suspect. Even in a patient not on such medication, fat grafting is not always reliable anyway. Unfortunately, there are no treatment options that combine the concepts of ‘not short lasting and not expensive’ when it comes to facial volume restoration. Your best choice under these circumstances is fat grafting and one has to accept that it is unknown what will happen with volume persistence. Another option is to combine temporal implants with malar/submalar fat grafting. Temporal implants are the easiest and least costly of all facial implants to put in and can easily be done under IV sedation as can fat grafting.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to change the look of my breasts. I don’t mind having small breasts but I just don’t like the sag. Do you think a breast lift alone will give me a good result? What are the benefits of implants with a lift? Is the combination better than a lift alone?
A: Your breast sagging and your questions about how to improve them are fairly classic. Your dilemma is not new and it can be hard to figure out what exactly to do. So let me break down into the structural problems. In sagging breasts, there are three elements to them that bother women. First is the lack of upper pole fullness. While a lift may make some immediate improvement, it will not be sustained. This is what implants are used for to create some permanent upper pole fullness. The next issue is the low nipple position that is either pointing forward but low on the breast mound or is pointing downward to the floor. This is what a lift does best, reposition the nipple back up higher and in a more centric position on the breast mound. Lastly, is the bottoming out of the lower breast tissue that hands over the lower breast fold. This also is what a lift helps with by removing skin and tightening the tissues on the lower pole.
This being said, I find in many cases that a breast lift alone can be disappointing particularly in the thin-skinned small breasted patient. It really requires an implant to create sustained upper pole fullness and some upward movement of the breast
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a jaw angle augmentation surgery done over a week ago and now that major swelling has subsided I’m noticing that my implants are way too big, they make my face look round, like a watermelon, and not long and squared like I wanted them to. My question is: can the implant be taken out, reshaped and placed back in? Do you recommend this or should new implants be ordered? Will the revision surgery have the same amount of swelling/downtime as the intial one? Thank you so much for taking the time to answer my questions.
A: Quite frankly, if I have heard these same concerns from one male patient who has had jaw angle implants, I have heard it from the last fifty. You are jumping the gun in trying to determine just one week out form surgery what the results will be. Jaw angle implants cause, by far, the largest amount of swelling of any of the facial implants. Patients generally swell up like a balloon and don’t even start to look human again until three weeks after surgery when maybe 50% of the swelling has subsided. I would not even try to judge the results obtained by these implants until at least six weeks after surgery…three months is even better. Swelling aside, there are numerous other factors which control the shape of the jaw angle afterwards including the original jaw angle deformity and what style of jaw angle implants were used. Size of the implants is one issue but style of the implant and where on the bone they were placed and how they were secured is even more important. Patience is the key for now. It is just as ‘easy’ later to adjust or switch out the implants at six weeks or three months as it is now. You will only benefit by patient and more healing time to make the right decision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been fighting my insurance company since last year due to a yeast infection under the pannus of my stomach. The insurance denied the surgery, saying it was cosmetic, but recently these huge purple marks have appeared and are very thin. A nurse friend said they feel like a blister about to pop and are concave. However, these marks keep spreading across the pannus. My question to you, is, would you, or do you know of a surgeon that would be willing to use me as a teaching subject and take me on as a case study and do the surgery as pro bono? I have had this yeast infection for 7 years and now I am at a standstill. Any advice you could offer would be more then generous. Thank you so much for your time.
A: Battling insurance companies to get coverage for abdominal panniculectomies is standard and the denials and appeals can go on for years. But this is fight you must continue and eventually you should win because you have a real medical necessity condition that justifies an abdominal panniculectomy. It is also a fight you must continue because you are not going to find a plastic surgeon to do it at their own expense. There are also numerous other expenses of surgery (OR, anesthesia, etc) that must be paid that go way beyond whatever a surgeon’s fee is.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have decided that I would like to have my cleft lip scar and nose asymmetry repaired. Besides the surgeries for primary repair as a child, I have never considered surgery, so I have no experience in what to look for, how to choose the right surgeon, etc. I was very impressed by your website and the way it explains things. I am very serious about having this procedure done, I just need to figure out the logistics with scheduling, recovery time, costs involved, etc. Please let me know what my next steps should be. Thank you very much.
A: Even with the best primary cleft lip and nose repair as an infant, growth and ongoing facial development of the scarred area will result in lip and nose asymmetries. Most of these secondary deformities are quite classic and include vermilion notching, a vermilion-cutaneous mismatch, wide philtral scarring of the lip and tip asymmetry with nostril slumping and widening of the nose. As an adult, the best nose repair comes from a complete septorhinoplasty with cartilage grafting and a cleft lip revision. These usually can be done during the same surgery. Recovery largely revolves around the nose and includes the wearing of a nasal splint for a week after surgery. You should be back to work within 10 days after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to remove excess fat in the pubic and labia area in order to wear pants and bathing suit more comfortably. It is terribly embarrassing when you have this puffiness sticking out in your clothes. I am not overly fat but my pubic area sticks out further than my stomach. What can be done to reduce this area? I have attached a front and side picture for you to see how big it is. Also I would like to know if I qualify for military discount since my husband is a retired Air Force veteran of Gulf War I and my son is active duty Air Force currently.
A: Based on your pictures, you are an excellent candidate for suprapubic mound liposuction. Fat removal in this area can make it quite flat and is a simple and highly successful contouring procedure of a small area. It can be performed under IV sedation as an outpatient procedure. There will be some mild swelling and bruising and it will take about 3 weeks before all goes down and you are in the benefits phase of the procedure. Because of your husband and son, you most certainly would qualify for a discount for the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a very small upper lip which is substantially smaller than my lower lip. I have had several consultations and the recommendations have ranged from injectable fillers, implants to a lip lift. I am confused by these different recommendations as there doesn’t appear to be a consensus as to the best thing to do. I have attached a picture of my lips for you to see and give me your recommendation.
A: As you have discovered there is a variety of lip enhancement procedures that approach making the lips more attractive in a variety of ways. In the end, they all have the same objective, making the vermilion of the lips more pronounced. (increased vertical height and fuller) Think of these procedures as minimally-invasive (non-surgical) to surgical. As a general rule, most patients should always start with injectable fillers because this treatment is the simplest and is completely reversible. What this tells you is whether the existing size of your vermilion can be adequately inflated to achieve the look you want. If it does, then you can ponder whether fat injections or implants may be a better long-term solution. If expanding the existing vermilion is inadequate or produces an undesired look (duck lips), then the location of the vermilion needs to be removed. This is where vermilion advancements and lip lifts have a role to change the vermilion-cutaneous junction and the amount of lip skin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, First I must say I’m very impressed with your forehead contouring method and I think I come to the right place for my procedure. I am an Asian male who had goretex custom implants placed for brow bone augmentation via a bicoronal incision and fixed with screws. From beginning I was unsatisfied with the result. It gave me extreme brow ptosis with a paralyzed left eyebrow that interferes with my vision. I can not raise my left eyebrow at all. The paralyzed left eyebrow seems like it is caused by implant placement which is placed slightly higher than the right eyebrow. I know because I can feel it. The brow ptosis dramatically changed my youthful eyes shape and made me like an old tired man. I have to keep raising my eyebrow muscles constantly everytime I meet people to make my face look ‘normal’. It has been three years since this surgery and I don’t want to look this way anymore. Now I’m considering brow lift to help my issue. Am I good candidate? What is the best brow lift method to address my complex issue? I tried to avoid bicoronal incision again because it left me with 1 cm width scar ear to ear with no hair growth at all in that area. I even want this ‘bald’ scar removed if possible. Can this brow lift method change my youthful eyes shape back like before?
A: To lift your brows now, the only option would be to re-use your bicoronal incision. The good news is that the scar needs to be excised anyway to obtain a substantial narrowing of it. That scar is unacceptable. That would work in helping with the browlift since the amount of brow movement upward should be roughly the same amount as the width of the scar that needs to be removed. I believe this will be successful. Whether it will get the brows elevated as much as you demonstrate with your hands may be overly optimistic but much improvement should be obtained.
As an aside, I suspect your left eyebrow paralysis is the result of an injury to the frontal nerve branch of the facial nerve on that side from the raising of the bicoronal forehead flap. It would be unlikely that the eyebrow doesn’t elevate because it is ‘stuck’ on the brow bone implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 26 years old and have a very flat midface. I would like to do something that will give my midface more projection but I don’t know what is the best thing to do. I read that some doctors use implants while other recommend injectable fillers. I have been through orthodontics to correct my crossbite and it is now perfect. But my face is still pushed in and unattractive with deep nasolabial folds. What do you recommend?
A: By description and as evidenced by your orthodontic treatment, you likely have some amount of natural midface retrusion with a corrected Class III malocclusion. This would indicate a more panfacial or significant midface deficiency of which injectable fillers would be a poor treatment choice. It would take a fair amount of filler volume to achieve a visible improvement not to mention the need for repeated treatments, provided a good aesthetic change could be achieved. There are a variety of facial implant options which can provide both improved midface projection and a permanent result. Malar, submalar, paranasal, premaxillary and infraorbital rim implants are all potential options for augmentation depending upon the amount and location of the midface retrusion. Most patients do well with combined malar and paranasal implants. However the malar deficicency usually has an infraorbital component as well. Similarly, the nasal base deficiency may include a more extensive premaxillary retrusion and not just the lateral pyriform aperture areas. A good eye is needed to determine the type of implant styles that would best treat any patient’s specific concave facial shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a condition known as facial lipoatrophy. From what I have read it is type III or IV based on how my face looks. I am 24 years old and have had this look since I was a teenager. It makes me look older than I really am and I am concerned if I look this way now what I will look like in 10 or 20 years. I have high cheekbones but they are very skeletal-looking with indentations beneath them with loose skin sitting atop them. What type of surgery will make my face look more normal?
A: The look of facial lipoatrophy is easily identifiable with loss of some or nearly all subcutaneous and buccal fat over the central portion of the face. Surgery must incorporate both hard and soft tissue augmentation since the problem extends over both bone-supported and non-bone supported facial areas. One successful treatment strategy is a combination of submalar implants to fill out the upper submalar triangle and fat injections for the lower submalar triangle and the sides of the face. Temporal implants can also be used for the always present temporal hollowing which is often overlooked in the treatment of facial lipoatrophy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Could my prominent, asymmetrical eyes be corrected with fillers? A nurse told me that the bones in one eye socket are further apart causing that eye to be able to stick out further. Could they be made even and the bulging eliminated? They are quite “bug eyed” to me which is just genetic. All the women in my family have these eyes. Also, the wrinkles beneath my lower lid when I smile– will the increased volume in that area from the filler eliminate them? Will it also correct the dark skin/shadow under my eye? I think they really age my face. But I think it’s lack of volume that causes it. How much would something like this cost in total? Do u use Restylane for this? I really appreciate your time.
A: In looking at your pictures, injectable fillers under the eyes is NOT going to correct you eye concerns. What you have is what is known as pseudoptosis. The eyes bulge out, not because they are too far forward, but because the bone around them (orbital rims) is recessive or deficient. You are not going to lift up the lower eyelid by placing injectable fillers underneath it, that simply will not work. What you need is to have the orbital rims built up with an implant material. For the lower eyelids this would be infraorbital rim implants. For the upper eye area, this would be brow bone augmentation. Understand that the problem is a bone deficiency of which it requires surgical augmentation not injectable fillers.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have lost weight and have an apron of loose skin that hangs over, plus some fat at my waist that I would love to not have to look at anymore. I have looked at your gallery and have seen a couple of pictures that are very close to my condition, and like the after photos. I would be very happy to look like that. I am 60 years young and still have a lot of living to do. I am very healthy with only a thyroid condition that I take a small dosage of synthroid to correct.
A: Your age of 60 is certainly not a limiting factor in having tummy tuck surgery. As long as you are healthy and have no restrictive medical conditions, which it appears you are, there is no reason not to enjoy the outcome of removal of an overhanging abdominal pannus. Such a removal can be very liberating and improves not only your clothing options and hygiene but your self-image as well. Tummy tuck surgery is performed as an outpatient surgery under general anesthesia. The biggest issue in after surgery recovery is that you will have a drain for 7 to 10 days afterwards. This is more of a nuisance than anything else as you can move about and shower normally.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions concerning adding implants to the top of the head. How thick can the implant be at most in your opinion? How is PMMA implants fixed to the top of the skull? Is there any risk of getting loose later and cause infection? Will it thin the skin?Thanks in advance.
A: The thickness of any skull augmentation that can be achieved is directly related to how much the scalp can expand over it. Short of a first-stage tissue expansion procedure, most scalps can stretch 5 to 7mms and have a tension free skin closure. Once you get anything over 10mm, a tension-free scalp closure may become more difficult. Anything cranial implant is secured by small titanium screws through a ‘rebar method’ when it comes to cranioplasty materials that are applied initially as liquid-powder or putty mixtures that then set up. Looseness or infection are two potential complications that I have not seen. There is always some slight tissue thinning around any body implant that expands the overlying tissue. But the scalp is very thick and any tissue thinning over a long time does not affect the skin or the hair follicles.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a little nervous about a cranial reshaping/augmentation procedure so if you don’t mind I have some questions regarding it. Does this type of surgery come with a high risk of complications/ what are the complications? From the location of my indentation can you give me a general idea of how big and where the location of the scar would be? How long would an open approach surgery take to correct my indentation/ how long would recover time take? How much would this surgery cost roughly? If my research is correct I understand their are different methods/ materials that can be used with an open approach can you explain them? and the pros/cons of them? What method would you recommend?
A: In answer to your questions. This is not a high-risk procedure. There are no major complications that I have ever seen. The complications are of the aesthetic nature, meaning how does it look, is it smooth, etc. You need access to both sides of the skull. There fore the incision would be bicoronal, meaning it would go across the top of the head just about from one ear to the other. Surgical time for this procedure is 2 hours. Your recovery would be very quick, so swelling but no significant pain and no real restrictions after surgery other than strenuous physical contact. That information will be passed along by my assistant. The other decisions/options about an open approach is the choice of cranioplasty material. With large surface area to be covered like your cranial indentations, the PMMA (acrylic) is the most affordable. I am not sure what you mean by method. This would be an open cranioplasty with midline bone reduction and build up of the deficient sides.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can a direct vertical incision be used for women with vertical bands of turkey wattle? I had a facelift 20 years ago when the platysma was tightened and there is no flesh left behind my ears (very bony and thin). If it were performed as an “H” on its side, then it may be confined to under the chin and not be so visible on the actual neck?
A: The answer is that direct necklifts can be done just as easily in women as in men. However the design to which you refer to is known as a submentoplasty where the scar is completely under the chin and not onto the neck. Direct necklifts, by definition, involve a vertical cutout of skin and fat down the center of the neck. But the cutout pattern always is like an H its side with the final incision closure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 42 years old and i have just one concern about my eyes showing a bit too much sclera and lack of support of lower eye lids…i had fillers injected but I must say that the improvemnet was mild to non existant and did little for the scleral show even if the lateral volume was improved. Also fillers tend to be pulled by gravity and the infraorbital fillers the shifts and becomes more of a feminized cheek implant. I was imagining that infraorbital rims will be more precise and long lasting. Also I was wondering if the rim itself will push the lower eyelid enough to show les sclera or if it would be better to tighten up the sides as well. I always found that I look much better when I squint slightly which makes me believe this is what i need…how natural doesthis procedure look? is it a spectacular change? Do rim implants shift as easily as jaw angles? Thank you
A: The position of the lower eyelid is affected by many factors but one of the most significant is the amount of bony support from the lower orbital rim. Adding permanent volume through an implant is a logical choice. The amount of volume added is dependent on the style and size of the infraorbital rim implant. Regardless of the implant, tightening the lower lid through a lateral canthoplasty is always advised/done. Moving the level of the lower eyelid up is never an easy task but the combination of infraorbital rim implants and canthoplasties gives the best chance for that to occur. Since I always screw the orbital rim implants in, like all facial implants, I have never seen implant shifting.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a midface deficiency which is causing the skin of my midface to sag alot causing it to look pigmented, I have been told I am more suitable for orbital rim implants (after many consultations for standard cheekbone implants) but it seem a subtle implant is all that can be used due to my skin not being very hefty. What I want to know is how far around from the nasion area around to the malar lateral area does the implant reach? Will it fill out the area on outer corner of eyes where a normal persons cheekbones would normally be located? I generally have good projection on the sides of my head, but I have developed a fat face appearance and I’m only 24, this is giving a pigmented look to the unsupported skin. It’s like I’ve lost a lot of weight which I haven’t as I’m only 150lbs.I have been told I could go with fat transfer after implants if I wanted a more drastic change later on down the road. Will subtle rim implants be enough to lift the sagging skin as it feels like there is a lot? My face has no angles like it used to and has become very doughy. I’m depressed over this as I simply don’t know what to do.
A: While I will have to see pictures of you, I can make some general comments in regards to infraorbital-malar implants. There are numerous styles and designs of orbital rim, malar and combined infraorbital-malar implants. Some do reach the whole way from the medial orbital rim around and onto the malar region and up on the lateral orbital rim. How much midfacial tissue lifting these implant styles do is limited. Some malar tissue elevation is obtained but more significant amounts will likely need some form of a midface lift done concurrently with implant placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a chin implant that was placed 35 yrs ago when I was 18. My dentist tells me that the bone has eroded behind the implant and that some teeth that are now moving in that area. It is a silicone implant. I know I have to get it removed but can I have a new chin implant or is that that? My surgeon said to take it out and consider a new implant when it is healed but I do not want another silicone implant and there’s a lot of info on the internet stating they too have had serious bone problems with silicone chin implants. Is this common? Thank you.
A: Never confuse passive implant settling with active erosion. Chin implants do not actively erode bone, they merely respond over time to the pressure of the overlying soft tissue and something has to give. This phenomenon can particularly be seen when the implant sits too high over the softer and thinner bone cortices in front of the roots of the mandibular incisor teeth. Obviously you have an old implant that is positioned too high, which is why it is closer to the tooth roots. A properly positioned chin implant sits down on the basal bone, some distance away from the level of the tooth roots. You simply could have the implant removed, an allogeneic bone graft placed into the cortical defect and a new chin implant placed in a lower proper position if desired. Whether that should be a silicone or Medpor implant is a matter of debate. I suspect the implant is small and, because it is positioned too high, probably has little actual influence on the horizontal projection of the chin.
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> What has happened is a natural long-term process that is not reflective of pathology or some mysterious substance leeching from the implant causing this bone/radiographic reaction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, thank you for doing the imaging. Regarding my chin and jaw I had something different in mind, I wanted something more defined and v- shaped for my jawline. Some implant that would probably wrap around my whole jaw and give me a more defined look. I’ve attached a picture of Matt Bomer to illustrate what I exactly have in mind and please tell me if I’m being realistic or not. If getting such a structure is a bigger job and you feel that a custom implant is more suitable, I’m more than fine with that. Too be honest doctor, I want to have everything perfect even its going to cost me more. Regarding the cheek bones? Do think augmentation is suitable for me or not?
A: The purpose of computer imaging is to transition the talking to a visual interpretation. It is a starting point for refining goals. What you have seen and do not like is what off-the-shelf chin and jaw angle implants do. They are fine for many patients but will not give a smooth jawline connection between the two. Only a custom wrap-around jawline design can do that.
I think using the picture of Matt Bomer is helping to define your objectives but you can never have his exact jawline because his facial tissues are thinner (less fat). Therefore, his jawbone anatomy is very well revealed including the angular flare. Your facial tissues are a bit thicker so you can end up somewhere between where you are now and his look.
In regards to the cheeks, I think they would also be helpful in achieving your desired facial look. I have done additional imaging based on these concepts.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering a jaw and/or chin augmentation procedure. I believe my chin would look better if increased length-wise, but I am unsure if a chin implant is able to achieve this (as opposed to the bone shift procedure). I am attaching some pictures so you can see my face from the front and side. I apologize about the poor lighting–I spent several months cultivating a beard, and these are the only pictures I have without the facial hair.
A:I have taken a look at your photos and feel that you are correct…your chin is deficient both horizontally and vertically. Your facial hair shows the vertical increase already and perhaps, consciously or subconsciously, this is why you grown it. Either a chin implant or a chin osteotomy can create vertical chin lengthening but it depends on what you want the overall dimensions of the chin to be. A chin osteotomy will lengthen the chin but will also narrow it in width by doing so. (unless a simultaneously placed thin extended implant is placed along the bony margin at the same time) A chin implant can make the chin longer and wider (more square) but it would have to be a custom implant. There are no off-the-shelf chin implants that create that effect.
Q: Dr. Eppley, I an a 45 year old female with a total avulsion of my left ear with skin graphing to cover the skin loss. My car accident was twenty years ago and the ear was found at the accident, however it was macerated and nonusable, as well as the tissue behind the ear. As I am getting older I am having numerous eye issues with severe dry eye syndrome and having to wear glasses and this is quite difficult with missing an ear. Unlike the lady in this segment, I do not have an ear lobe and no extra skin. I would even be happy with some sort of way to hold up my glasses. I wanted to know if there was anything that could be done to help me function normally to wear my glasses. Look forward to your response. Thank You.
A: I think there are two approaches to your ear reconstruction depending upon exactly what you want the final outcome to be. The skin graft in place precludes any attempt at making and inserting a cartilage framework through a traditional microtia reconstruction approach. This requires supple skin that can either be elevated or tissue expanded. The standard approach would be the insertion of endosseous implants followed by the attachment of a prosthetic ear. This provides good prosthetic retention and should easily hold up a pair of glasses. A secondary approach would be to create a shelf of cartilage above the skin graft or at its edge onto which glasses could rest. This will not create an ear but more like just the upper ¼ or 1/3 of it. Whether this is possible will require reviewing a picture of what the ear site looks like and the exact location of the skin graft.
Dr. Barry Eppley
Indianapolis, Indiana